REPORT OF THE POLICY SEMINAR ON

TRANSFORMING THE FOOD AND NUTRITION LANDSCAPE IN

ASSAMMarch 29, 2017

NEDFi House, Guwahati

© CFNS 2017

Photos: © CFNS 2017

Any part of this document may be freely reproduced with appropriate acknowledgement

Inter Agency Group Assam (IAG-Assam) C/o: Doctors For You, House No: 10, Jagesh Das Path, Near Little Flower School, Hatigaon, Guwahati - 781038, Assam Tel (0361) 2225687,  97060084882 (Convener) 7399016122 (Coordinator) Email:iagassam@gmail.com,  Website: www.iagassam.org

Coalition for Food and Nutrition Security B-40, Qutab Institutional Area New Delhi, Delhi - 110016 Tel: 011 4105 8548 Website: www.nutritioncoalition.in

CONTENTS

ABBREVIATIONS

BACKGROUND

OPENING SESSION

POLICY SESSION: EVIDENCE AND IMPACT

POLICY DIALOGUE

KEY POLICY ACTIONS ANNEXURE (A)

1

2

5

9

16

19

25

AARR: Annual Average Rate of Reduction AARI: Annual Average Rate of Increase ANC: Antenatal Care ANM: Auxiliary Nurse Midwifery ASHA: Accredited Social Health Activist CDDMASS: Center for Development and Disaster Management Support Services CFNS: Coalition for Food and Nutrition Security CSO: Civil Society Organization FRU: First Referred Units IAG: Inter Agency Group IAS: Indian Administrative Service ICDS: Integrated Child Development Scheme IFA: Iron-Folic Acid IMR: Infant Mortality Rate MDM: Midday Meal MGNREGA: Mahatma Gandhi National Rural Employment Generation Act MMR: Maternal Mortality Rate NFSA: National Food Security Act NFHS: National Family and Health Survey NGO: Non Government Organization NHM: National Health Mission NRC: Nutrition Rehabilitation Centre PDS: Public Distribution System SDG: Sustainable Development Goals SNP: Supplementary Nutrition Program TPDS: Targeted Public Distribution System UNICEF: United Nations Children’s Fund WASH: Water, Sanitation and Hygiene WHA: World Health Assembly WHO: World Health Organisation

ABBREVIATIONS

1

The Landscape: Malnutrition; a Silent Emergency engulfing the state

Assam is one of the backward states in North East India and its marginalized population mainly depends upon food and nutrition entitlements mandated under The National Food Security Act (NFSA), 2013. Despite numerous measures to ameliorate the conditions, Assam has not shown much improvement in its health and nutrition indicators. With 36.4% children under 5 years of children stunted and Infant Mortality Rate (IMR) as high as 48 (Source – NFHS), Assam continues to be one of the five states of the country in this regard. Various studies suggest that 1% loss in adult height due to stunting contributes to 1.4% loss in productivity and stunting may reduce IQ by 5-11 points.

Mothers who received full antenatal care (ANC) is 18.1%. The rate among the children between 6-23 months who were breastfed is 8.7% and the percentage of children between 6-8 months with minimum acceptable diet is 49.9%. 46% of women and 35.6% children are anaemic in the state. Anaemia has bearing on productivity and eliminating anaemia can result in 5-17% increase in adult productivity.

There is a rising obesity among the men and women. 13.2% adult women and 12.9% adult men are obese, although childhood obesity is very low. Good sanitation, hygiene and safe drinking water have a bearing on good health and nutrition. Only 47.7% households in Assam are using improved sanitation facilities. However, the conditions of the workers in the tea gardens, migrant workers, inhabitants of char (river islands) is worse than that of the general population. Poor socio-economic condition, illiteracy, over-crowded and unhygienic living conditions in the residential colonies make tea garden populations vulnerable to malnutrition and various communicable diseases.

Different studies show that high prevalence of undernutrition, worm infections, skin infection, and respiratory infections, including tuberculosis, filariasis, back pain and micronutrient deficiency disorders like anaemia were widespread among the tea garden workers.

NFHS data trends for stunting in children and IMR in Assam

(Source – NFHS)

NFHS fact sheet IMR Stunting

NFHS 1 88.7 -

NFHS 2 69.5 33.9% (24 to 35 months)

NFHS 3 66 46.5% (under 5 children)

NFHS 4 48 36.4% (under 5 children)

BACKGROUND

2

Good nutrition is essential for a healthy immune system, higher order cognitive ability, growth and productivity, and achieving a demographic dividend. Assam’s continuing high levels of poverty and inequity can be attributed largely to its malnutrition and food insecurity.

Improving access to sustainable food and nutrition: The need and relevance for a State Food and Nutrition Commission

a) The National Food Security Act (NFSA)-, 2013: A comprehensive regulation for the ‘food and nutrition security in a life cycle approach’. The National Food Security Act (NFSA), 2013, has a clear mandate for adopting the ‘food and nutrition security in a life cycle approach’. Apart from food and nutrition entitlements through public funded programs, the Act mandates a) provisions for advancing food security: revitalization of agriculture, food value chain, and safe drinking water b) Women Empowerment: ration cards will be in the name of eldest woman in the family c) Nutrition, health and education support to adolescent girls d) Safe drinking water, nutrition, health and education support to adolescent girls and e) Exclusive breastfeeding for children under 6 months.

b) NFSA 2013 mandates a State Food Commission for regulatory enforcement and monitoring As per the NFSA, 2013, state government shall by notification constitute a ‘State Food Commission’ which will function as a key and powerful institution in the state to ensure proper entitlements, access and control over food and nutrition programs for the poor and marginalised. In compliance to the NFSA-2013, in its endeavour to establish an empowered Food and Nutrition Commission, the Government of Assam should on a priority basis issue a notification on drafting ‘Assam State Food and Nutrition Commission Rules, 2017’ and solicit public opinion.

c) State Food Commission to ensure entitlements, transparency and public accountability in public funded programs The Act prescribes coverage of minimum 67% of the state population and key food and nutrition entitlements like Targeted Public Distribution System (TPDS), Integrated Child Development Service (ICDS) and Mid-Day Meal (MDM) programs in the state. The NFSA also mandates provisions for advancing food security, revitalization of agriculture, food value chain, safe drinking water, nutrition, health and education support to adolescent girls, exclusive breastfeeding for children under 6 months, and maternity benefits.

As per the Targeted Public Distribution System (TPDS) , identified priority households shall receive 5kgs of food grains per person per month at a subsidized price, and households covered under Antodaya Anna Yojna are entitled to receive 35 kilograms of food grains per month at a subsidized price.

3

Nutrition entitlements in Mid-Day Meal and ICDS Supplementary nutrition program are tabulated below:

Assam, to be an exemplar state by establishing a State Food and Nutrition Commission

So far, only five Indian states (Bihar, Uttarakhand, Haryana, Odisha, and Punjab) have established independent food Commissions. Other states have entrusted the responsibility of the Food Commission to state Information Commission or Women's Commission. In the light of the high incidence of malnutrition and the mandate of the NFSA for adopting the ‘food and nutrition security in a life cycle approach’, Assam will, by establishing an empowered State Food and Nutrition Commission will emerge as an exemplar state in India. . The effective implementation of Food Security Act can transform the nutrition and food security landscape in the state and enable the state to become a global pioneer in food and nutrition.

Keeping this in mind, a policy seminar on “Transforming the Food and Nutrition Landscape in Assam” was organised by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Inter Agency Group (IAG), Assam on March 29, 2017 at NEDFi House, Guwahati, which was attended by various stakeholders and cohorts relevant to this theme.

Category Type of meal Calorie (kcl.) Protein(g)

Children 6 months to 3 years Take home ration 500 12-15

Children 3-6 years Morning snacks and hot cooked meal

500 12-15

Children 6 months to 6 years- who are malnourished

Take home ration 800 20-25

Lower Primary classes Hot cooked meal 450 12

Upper primary classes Hot cooked meal 700 20

Pregnant women and lactating mothers

Take home ration 600 18-20

4

The opening session of this seminar was chaired by Mr. Bhaskar Barua, Member Governing Board, CFNS. The welcome and introduction for this session was given by Mr. N.M. Prusty, Mentor cum Director, Center for Development and Disaster Management Support Services (CDDMASS) and Member Governing board, CFNS. He pointed out that one of most glaring shortcomings that intervention programs in the field of food and nutrition is the lack of available data that can be used to analyse the existing problems and formulate strategies to resolve them. The integrity of the data that is available to us is also questionable. Malnutrition is not just a social or a health issue, it is both. We can only begin to take steps towards eradicating malnutrition as a whole if we can ensure a synergy between the two. The required legislations, such as NFSA and MGNREGA exist and sufficient number of government schemes such as MDM, ICDS and TPDS etc. are in place to tackle the problem of malnutrition. The challenge lies in implementing these acts in the entirety and making these umbrella programs efficient and effective. We also have to ensure the engagement of all the stakeholders pertinent to NFSA, and a comprehensive social audit process that will regularly monitor the implementation of NFSA. Unless there is a proper convergence of good politics, governance, and legislation, we cannot get rid of malnutrition.

Thereafter Mr. Basanta Kumar Kar, Chief Executive Officer, CFNS gave a presentation on the landscape and pathways with regards to food and nutrition security in Assam. The first question that arises when one talks of nutrition is why invest in it? Over 2 crore people in India between the ages of 15 to 59 suffer from malnutrition, and consequently they are not fully capable of adding to the growth and productivity of the country. Reports suggest that malnutrition suffered by a child during their first 1000 days is irreversible. This period begins at the antenatal stage and ends at the age of two, which is why it must be our priority to ensure that health services and supplies, including supplementary nutrition reaches pregnant women and infants by choosing the right delivery and business models with strong frameworks for food safety, regulation, enforcement, and monitoring. Assam faces the double burden of both obesity and stunting. To reduce these cases, we need to address all causes of anaemia, not just iron deficiency. Milk needs to be fortified with more nutrients. We need to explore methods for practicing and promoting climate-smart nutrition-based agriculture adding to the basket of nutrition rich local food. Apart from deficiencies, other major causes of malnutrition are bad hygiene and sanitation practices, high-levels of exclusion in tea-garden and char areas and of migrant workers, inter/intra-household disparities, mental health disorders and gender-based violence. To ensure a malnutrition-free state, we have to address all forms of exclusion and provide inter-personal counseling to those who need it. Community participation is quintessential in bringing any kind of change to the society, and it is important to understand the indispensable role of women in the same. A system needs to be structured wherein each hamlet in the state has women change leaders fighting against hunger and malnutrition. A State Nutrition Policy needs to be conceived with measurable targets that have to be achieved by 2025. The functioning of the Nutrition Rehabilitation Centers also needs to be more efficient.

OPENING SESSION

5

The second address of this session was given by Mr. Amrit Kumar Goldsmith, Chairperson (IAG), Assam on issues related to food and nutrition security in Assam from a civil society perspective. He emphasized that we should encourage procuring food locally as much as possible. Doing this makes it easier to focus on the nutrient content in the various foods produced and consumed, while also enriching the livelihoods of the people engaged in agriculture. We also need to regularly monitor the weight, height and overall growth of all children in the state by engaging civil society organizations working at the grassroots to ensure that the child is getting all the necessary nutrients in the food commonly consumed. IAG can also provide last-mile connectivity for government schemes.

This was followed by an address by the Chief Guest, Mr. Vinod Kumar Pipersenia, IAS, Chief Secretary, Government of Assam. He said that our greatest problem as a society was our ignorance and confusion revolving around the topic of nutrition, cascaded by the misinformation propagated by food and beverage commercials. We need to carefully inspect by means of baseline surveys the problem of malnutrition and narrow down the primary causes so as to deal with them. Reports indicate t that in Assam roughly 86% of the babies are of normal weight at birth, which means that most cases of malnutrition occurs after the child is born, and not due to antenatal factors. We need to keep digging into these numbers and identify the root causes and develop targeted intervention mechanisms to alleviate the problems of undernutrition and over-nutrition as our topmost priority. He ensured that there is no lack of resources or political will at the government’s level when it comes to food and nutrition. It is therefore our immediate collective duty to amplify effectiveness of all relevant schemes and acts at all levels. He also acknowledged the importance of women in this fight. Sufficient knowledge and resources need to be dissipated among them, along with their empowerment. We need to develop a road map to ensure Assam is free of poverty and hunger by 2030. In pursuance of the same, the Chief Secretary suggested that CFNS and the Centre for Sustainable Development Goals established by the state government enter into Memorandum of Understanding.

The fourth address of the session was by Dr. R.C. Panda, Former Secretary, Government of India and Member Governing Board, CFNS, who presented his comments on the Acts and Rules pertaining to food and nutrition security. The first requirement of the Act should be the setting up of a State Food Commission, keeping in mind the provisions in sections 4(1), 5(1)(a), 5(1)(b), 5(2), and 6 of NFSA 2013. The Commission will consist of a chairperson, a member-secretary, and five other members, of whom at least two should be women and one should be a person belonging to the SC category and another to ST. The method of appointment of these functionaries have been prescribed in section 16 of NFSA 2013. The functions of the commission are as follows: a) monitor and evaluate the implementation of the Act; b) either suo moto or on receipt of complaint inquire into violations of entitlements provided

under Chapter II; c) give advice to the State Government on effective implementation of the Act;

6

d) give advice to the State Government, their agencies, autonomous bodies as well as non-governmental organisations involved in delivery of relevant services, for the effective implementation of food and nutrition related schemes, to enable individuals to fully access their entitlements specified in the s Act;

e) hear appeals against orders of the District Grievance Redressal Officer; f) prepare annual reports which shall be laid before the State Legislature by the State

Government. g) can exercise the powers of a civil court under the Act. Under Section 40(1), The State Government may, by notification, and consistent with the Act and the rules made by the Central Government, make rules to carry out the provisions of this Act. Such rules may provide on the following matters:- a) identification of priority households under sub-section (1) of section 10; b) internal grievance redressal mechanism; c) institutionalization of State Food and Nutrition Commission; d) Transparency in TPDS, ICDS, and MDM; e) Social Audit protocol for TPDS, ICDS, and MDM; f) Setting up of Vigilance Committees; He also listed the obligations at the Central and State levels. The Central Government should allocate the required quantity of food grains of acceptable quality from the central pool to the State Government. In cases of shortages in quantity and sub-par nutritional quality too the Central Government should help offset the shortage from the central pool. The State Government should enforce effective implementation and regular monitoring of these schemes, institute vigilance committees, implement the TPDS and ICDS supplementary nutrition, and mid-day meal programs. The only way forward towards achieving a malnutrition-free state is the institutionalization of various structures and systems under the Act, and pinpointing areas for customized intervention after a location-specific benchmark study of the problems.

The fifth address of the session was by Mr. Ranglal Jamuda, Former Secretary, Government of India and Chairperson, Odisha State Food Commission on the role of the State Food and Nutrition Commission toward improving access to safe and nutritious food. His insights from being engaged with the Odisha State Food Commission helped bring to light a few important points that the Assam State Commission when set up, could use as reference. Samples from the food supplied in MDM and SNP should be tested regularly by the food testing lab. Any discrepancy found in the samples should be addressed immediately. The nodal departments relevant to all three should facilitate to ensure effective implementation of MDM, TPDS, and ICDS. The activities of the donor agencies and the CSOs should be coordinated.

The last address of this session was given by the Special Guest, Dr. Rajesh Kumar, Joint Secretary, Ministry of Women and Child Development, Government of India about his vision for A Suposhit Bharat. He said that it is important to bring in a nutrition commission because we need to have a vigilance mechanism so that there is independent monitoring and

7

enforcement of MDM, ICDS, and TPDS. The nutrition needs of a child should not stop after the first 1000 days. Receiving proper nutrition is essential even after the first two years of our lives. In order to ensure this, our society’s behavior towards nutrition needs a complete overhaul. We need to realize that sanitation is as guilty of malnutrition as is iron deficiency. Proper immunization of every child in the state should be done , and their growth monitoring should be tracked in real-time using available information technology. When collecting information for health reports, the north-eastern tribes should be segregated and treated separately from the inhabitants of mainland India. Due to vast differences in ethnicity, and hence eating habits, one umbrella plan will not solve the problem of malnutrition in all pockets of the country. All areas should be separately studied, and customized plans of action should be devised for each of them.

8

This session was chaired by Dr. R.C. Panda, Former Secretary, Government of India and Member Governing Board, CFNS and co-chaired by Dr. Rajesh Kumar, Joint Secretary, Ministry of Women and Child Development, Government of India.

The first address was a presentation by Dr. Neha Raykar, Lead Economist, Public Health Foundation of India on the commitments and action on achieving health and nutrition targets of SDGs and WHA. Goal 2 of the post-2015 SDGs is to end hunger, achieve food security, improved nutrition, and promote sustainable agriculture. Further, target (2.2) states: by 2030 end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons. The WHA: Global Nutrition Targets 2025 are: (a) 40% reduction in the number of children under-5 who are stunted. (b) 50% reduction of anaemia in women of reproductive age. (c) 30% reduction in low birth weight. (d) No increase in childhood overweight. (e) Increase the rate of exclusive breastfeeding in the first six months up to at least 50%. (f) Reduce and maintain childhood wasting to less than 5%.

POLICY SESSION:EVIDENCE AND IMPACT

Anemia in women of reproductive age in the Northeast

Pre

vale

nce

(%

)

0

15

30

45

60

MZ NL MN AR AS All India TR ML

56.254.553

4640.3

26.423.922.5

The prevalence of anaemia in the state of Assam is significantly lower than the rest of the state. The numbers still need to be reduced, though.

9

As is observed from the chart above, the prevalence of stunting, wasting, and low birth weight in Assam is lower than the national average.

Stunting, wasting and low birth weight in the Northeast

Pre

vale

nce

(%

)

0

13

25

38

50

TR MZ NL MN AR AS All India ML

10.4

18.6

13.611.5

7.3

18.9

2.2

18.515.3

21

1717.3

6.8

11.2

6.1

16.8

43.8

38.436.4

29.428.928.62824.3

Stunting (under-5)Wasting (under-5)Low birth weight (under-3)

Exclusive breastfeeding in first six months in the Northeast

Pre

vale

nce

(%

)

0

20

40

60

80

MN TR AS MZ AR All India NL

44.5

54.956.560.663.5

70.773.6

Assam has a higher rate of exclusive breastfeeding in the first six months of a child than the national average.

10

Trends in WHA nutrition indicators in Assam (2006-2016)

Pre

vale

nce

(%

)

0.0

17.5

35.0

52.5

70.0

Stun

ting

Anem

ia in

wom

en

Low b

irth wei

ght

Overw

eigh

t

Exclus

ive b

reas

tfeed

ing

Was

ting

17

63.5

13.6

46

36.4

13.7

63.1

1.2

19.4

69.5

46.5

20062014/16

Required rates of improvement to meet WHA targets in 2025

Source: Data Note prepared by Amrutha Jose for POSHAN, IFPRI, March 2017

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While the rates of stunting and anaemia in the state have gone down, efforts still need to be put in to achieve the annual average rate of reduction (AARR) required to meet the WHA targets in 2025. Exclusive breastfeeding up to six months of age has increased, but not enough to meet the recommended AARI to meet WHA targets. The rate of wasting, however, has actually increased since the past leading to a negative AAMR. Huge interventions are needed in this particular context if we are to achieve the targets set by WHA by 2025. The following key observations and recommendations were noted: • Considerable reduction in stunting and women’s anemia. • Wasting rates in Assam are very high and have worsened over time. • IFA supplementation rates of mothers and children are very low, which could be due

to supply constraints and compliance/adherence issues. • Improvement in women’s status and WASH indicators will be critical to accelerate progress

towards achieving WHA targets. Further visual representations have been attached in Annexure (A).

The second address was on strengthening home contact and interpersonal counseling for a better nutrition outcome by Dr. Subrata Kumar Dutta, India Coordinator, Food Fortification Initiative. He emphasized the roles and responsibilities of Anganwadi workers for a better nutrition outcome. 60% of Anganwadi workers are 10th pass, while 10% are graduates. Naturally they don’t have sufficient knowledge for proper service delivery; moreover in villages they are highly vulnerable to being influenced by politics and panchayats. As a result home visits are very rare, only 20% of ICDS and Anganwadi workers do home visits once a month which is insufficient. The knowledge of antenatal and postnatal care, on the part of Anganwadi workers has huge gaps, especially in the context of Assam. 80% have the knowledge of breastfeeding which is good enough, but in some pockets like Cachar and Kamrup the numbers are very low. We should try to replicate the concept of “My Plate” prevalent in Indonesia, in India. “My Plate” means consumption of a balanced diet which comprises of food that contains all the essential nutrients. . He also talked about the need for community participation. Communication channels that are opened to percolate every social strata in order to generate awareness should be designed after consultations from participatory programs with the community. Interpersonal communication training programs should be organized in the Anganwadi centres. Antenatal care is highly insufficient in Assam. Campaigns should also be conducted to educate women about balanced diets.

The third address of the session was given by Ms. Sharmistha Chakraborty, Manager- Membership Engagement, Knowledge Management and Communication, CFNS on Women and Nutrition. Better nutrition means stronger immune system, fewer incidences of illness and better health. The nutritional status of women is important both for the quality of their own lives and the survival and health development of their children. Malnutrition in women leads to economic losses for families, communities and state because malnutrition reduces women’s ability to work and can create ripple effects that stretch through generations including cognitive impairment in children and low productivity in adults.Women’s bargaining

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power decides the extent of their influence on how household resources are channeled towards health and nutrition needs. Women’s multiple and unshared responsibilities have potentially negative impacts for child health and nutrition outcomes. Women, especially pregnant and lactating who experience exacerbation of mental distress, disruption in self-care including dietary intake, have aversive pregnancy outcomes (e.g. stillbirths, abortions, low-birth-weight babies, etc.). Randomised Control Trials in states like Odisha, Jharkhand in India and in Nepal and other South Asian Countries have conclusively established that community mobilisation through women’s groups can reduce neonatal mortality and improve maternal health (LANCET 2010). A study in Brazil showed that income accruing to women has a larger positive impact on child nutrition status (UNICEF). Witnessing violence between parents may also increase children’s psychological stress, which has been shown to negatively influence their health (Wyman et al. 2007; Caserta et al. 2008). It has been observed that hamlet level Women Change Leaders in Chhattisgarh and Bangladesh have significantly contributed home contact outcome and addressed exclusions. The following policy recommendations were suggested to address women’s nutrition: ● Recognize Women’s Nutrition as an agenda of action: A policy and investment priority. ● Understand women’s nutrition: A comprehensive nationally representative state survey

with integration of key social, gender and cultural indicators to understand the issue, prevalence.

● Set SMART Goals in line with WHA Targets and UNSDGs. ● Mainstream women’s nutrition in policies and programs with relevant departments. Create

avenues for women to have access to information and services related to nutrition in schools, workplaces, and youth-oriented health programs.

● Promote inclusive, participatory approaches to state and district level planning for program design and implementation.

● Promote women’s empowerment and advance gender equality. Develop women’s life skills to avoid early marriage and early pregnancy.

● Prioritize integrated, cross-sectoral approaches to nutrition to address all the underlying causes of malnutrition.

● Increase investment to build capacity for whole-of-state-government planning, coordination, implementation, and make nutrition a priority in state budget.

● Integrate mental health into primary care. ● All new ration-cards shall be issued in the name of eldest woman of the household as

head of the household in line with the provisions of National Food Security Act, 2013. ● Promote women self-help groups (SHGs) and Local Government Bodies on decentralized

procurement, processing, and distribution of food and nutrition products and services. ● Promote women and adolescent girls as Change Leaders in each hamlet to promote

health behavior and address social and geographical exclusions. By improving the nutrition of adolescent girls and women, the state can reduce healthcare costs, increase intellectual capacity and improve adult productivity.

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The fourth address of the session on addressing social and geographical exclusion in food and nutrition by Mr. S.S. Meenakshisundaram, Director, Department of Social Welfare, Government of Assam. Social exclusion is caused due to religious and historical/cultural reasons. There are a variety of shades and categories of vegetarianism and non-vegetarianism, and the concept of totem in tribal communities. There are three categories of responses to redress social exclusion: reactive, proactive, and sustainable. The reactive responses include food research and awareness generation, behaviour change communication, malnutrition detection and provision of nutritive food, nutrient and micronutrient supplementation, and forward positioning. The proactive responses include: advance positioning and provisioning of nutritive foods and food supplements, and a multi agency approach – Agriculture, Veterinary, Health, Education, and Social Welfare Departments to address it. The sustainable approach includes: Social mobilization and demand generation, supply chain management – government and free market facilitation, resource allocation and policy framework support, feedback loop, and research and development. Geographical exclusion is caused due to availability (or lack thereof) because of natural selection, climatic considerations, transportation challenges, and unpredictable factors like global climate change. Again, there are three categories of responses to redress social exclusion: reactive, proactive, and sustainable, which are the same as those for social exclusion. We also need to generate awareness about the impact of negative food practices, as well as abusive food (liquor and other intoxicants).

The fifth address of the session was by a representative of the Department of Horticulture, Government of Assam on climate and nutrition sensitive agriculture. He talked about the benefits of rooftop gardening in urban areas, and mushroom production. According to him, there is a surplus production in Assam of fruits and vegetables. He suggested the need of setting up food processing centre in Assam in collaboration with various stakeholders for preserving the nutritional value in food.

The last address of this session was about the challenges in WASH and nutrition perspectives by Mr. Nripendra K. Sarma, AEE (PHE). In the context of WASH, public health depends on safe drinking water and safe sanitation practices. One of the major causes of concern for Assam is the high dependence of the people on groundwater based supply, which is heavily contaminated in some areas. Water borne health risks arise from microbial activity and chemical contamination. WHO reports reveal that contaminated drinking water is one of the major causes of 80% of our diseases. Water management approaches need to be decentralized, which will be applicable at both public waterworks as well as the household level. The following points were noted for hygiene promotion: • Systematic dissemination of information on hygiene-related risks. • Identification of area-specific social, cultural/religious factors to use as a basis for hygiene

promotion communication strategy. • Targeting all sections of all ages, prioritizing women interventions. • Use of interactive Hygiene communication methods.

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• Prioritizing hygiene promotion activities/messages based on area / community specific KAP studies.

• Monitoring key behaviour. He concluded by emphasizing the need of using sanitary toilets in rural areas. In many cases we see that toilets are constructed but most of them are kaccha toilets, which are more dangerous than the open defecation. Increase in awareness levels among the people living in rural areas is very important for eradicating infections from homes.

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The final session of the policy seminar was the policy dialogue session that was essentially a question and answer session with inputs from the various panelists. The panel comprised of Mr. Samir Kumar Sinha, Commissioner and Secretary, Department of Health and Family Welfare, Govt. of Assam, Mr. Rupak Kr. Mazumdar, Registrar, Cooperative Societies, Assam, Dr. R.C. Panda, Former Secretary, Government of India and Member Governing Board, CFNS, Mr. Ranglal Jamuda, Former Secretary, Government of India and Chairperson, Odisha State Food Commission, Dr. Rajesh Kumar, Joint Secretary, Ministry of Women and Child Development, Government of India, and Mr. N.M. Prusty, Mentor cum Director, Center for Development and Disaster Management Support Services (CDDMASS) and Member Governing board, CFNS. It was chaired by Mr. Bhaskar Barua, Member Governing Board, CFNS.

Mr. Samir Sinha eloquently stated that common platforming of the various agencies working together is very important. The Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) in the state is almost entirely due to nutritional insecurity of pregnant women. One of the key gaps that we notice is anaemia in pregnant women, which is quite pronounced in the state. There are communities and geographies where this is one big problem, such as the char areas and the tea garden areas. The Health Department did a complete analysis of these areas to dig into why the IMR and MMR was abysmally low, and whether this problem was specific to a certain geography only or the state throughout. A complete survey of 780 tea gardens was done, and it emerged that MMR in these areas can go as high as 456 out of 1000, compared to the national average of 167, and the state average of 300, which is a noticeable gap soliciting urgent interventions. Thereafter, a screening and data analysis of the pattern of anaemia in these communities was done. There are five broad schemes that the National Health Mission (NHM) has been implementing throughout the state. The first is Mother’s Absolute Affection, which popularizes and creates public awareness of the importance of exclusive breastfeeding for six months, and breastfeeding thereafter. The second is the establishment of Nutrition Rehabilitation Centre, which is very crucial in providing supplements which are required for the development of a baby. The children are categorized as per their nutritional status, after which measures are taken and medicines are prescribed and supplements are given. NRCs are currently running in 19 districts of Assam. Ideally it should be part of the district hospitals, but the NHM has taken them further and they are now the First Referred Units (FRU) in their districts. Proper training of the health care providers posted in these NRCs is important. Then, there are the Nutrition Counseling and Management Centers, which is a service point in existing health facilities. Basically, they do counseling on the basis of the nutritional status. No medication or supplements are provided here. The fourth scheme of NHM is Mission Tejaswee, which is a set of activities implemented in an intensified manner for the prevention and treatment of anaemia across the state with equal focus on all 27 districts under the National Iron+ Initiative. The activities mainly include: intensification of advocacy activities, awareness generation activities, administration of IFA syrup to children 6-60 months by ASHA, distribution of IFA tablets by ANM to pregnant woman and lactating mothers with a goal to intensify ANC drive for ensuring high coverage

POLICY DIALOGUE

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of IFA tablet consumption. The main objective is to ensure high coverage of ANC package including IFA administration in pregnant women, effective efforts to increase the administration and compliance of IFA syrup among children aged 6-60 months. The last of these schemes is accelerating the administration of vitamin A via fortification or supplements, and the de-worming of children in the state. In order to ensure that every conceivable health facility is provided in the tea-garden areas, 80 mobile medical units will be launched in tea-gardens in April 2017 which will stay in each tea-garden area for five days consecutively and provide health care and treatment to all those in need.

Mr. Rupak Kr. Mazumdar talked about the challenges he faced when he was the Director of Food and Civil Supplies Department. The process of NFSA started around 2009. Drafts were published, a lot of workshops took place, and after regular meetings and deliberations the draft for NFSA came out in 2011. In Assam, the work was started by creating a group of four ministers, three MLAs, and various members of the administration who sat together for a fortnight to discuss what could be done. One concern was about how to cover the tea-garden areas in Assam. The provisions in NFSA states that in the rural areas 75% of the population, and in the urban areas 50% of the population has to be covered, which was done on the basis of cost of living index. As far as Assam is concerned, Government of India mandated that 84.17% of the rural population, and 60.35% of the urban population has to be covered. This started at the Gram Panchayat level. In case of tea-garden areas, six to seven tea gardens fell under the same Gram Panchayat on an average. If 84% of people in the tea garden were covered, 16% would be left out. All members of tea-gardens are more or less at the same socio-economic and nutritional level, and hence it became impossible to decide who could be left out. It was then decided that in these areas NFSA would function at the block level. One of the biggest challenges that he faced was with TPDS. There were a large number of bogus BPL cards in circulation which led to ghost beneficiaries of rice distribution. The only way to tackle this issue is the digitization of ration cards.

The following suggestions were made during this session:

• Forming of a State Advisory Body on Nutrition which will largely focus on Knowledge Management Areas and replication.

• Forming of village Health, Nutrition and Sanitary Committee at the village level, and involving community people. Capacity building of workers of the committee.

• Care must be taken during the time of selecting volunteers in village hamlets. Volunteers should be dedicated towards making the programme effective and sustainable.

• Nutritional illiteracy is very high among the ICDS & Anganwadi workers, emphasis should be laid on enhancing knowledge on nutrition with regular awareness programs and trainings.

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• A state-level Food and Nutrition Coalition, which will develop partnership with IAG and Food and Nutrition Coalition.

• Inter Agency Group, Assam needs to take a call and identify member organizations and implement the programs. Member organizations will also have the opportunity to share their ideas and try to improve the current levels of indicators.

• UNICEF adopted a special intervention with regard to nutrition, and a silent transformation is happening in the tea garden areas of Dibrugarh district. The same method can also be customized and then replicated in other parts of the states after location-specific research.

• Integrate four to five departments and involve the Civil Society Organizations. Develop and institutional mechanism for social service sectors which encourages community based initiatives.

After all the suggestions were carefully considered and deliberated upon, a document on the key policy actions that emerged during the course of the seminar was created, which was distributed among all participants of the seminar, and they were asked to send their feedback on the same by April 10, 2017. This document has been attached in the next chapter.

The Vote of Thanks for the seminar was given by Dr. Mridul Deka, Convener, IAG.

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There is every reason to believe that Assam which is endowed with rich natural and human potential and is on its way to emerge as a developed state, has bright prospects to emerge as a nutrition pioneer. Although there have been improvements during the last decade, Assam has some leeway to make up in this regard, lagging behind in key nutrition outcomes. The prevalence of stunting and wasting among the under-5 children is 36.4% and 17%, respectively (NFHS-2015-16). Anaemia is all pervasive. Stunting, anaemia and other micronutrient deficiencies inhibit productivity, proper cognitive development and health outcomes. Zero hunger and good nutrition has the power to transform and empower present and future generations. With investments in food and nutrition related initiatives the state can succeed in removing the backward tag that has plagued generations and get rid of the age old poverty.

A. Short Term- 1-2 years

1. Setting and achieving Measurable Targets by 2025 (in line with World Health Assembly Targets) • A state- free from hunger • Child stunting- cut the number by 40% • Child wasting- to less than 5% • Child overweight- no increase • Anaemia- cut anaemia in women of reproductive age by 50% • Exclusive breastfeeding- increase to at least 50% • Focus on Deworming + Open Defecation Free society • Low Birth weight- cut low birth weight by 30% • Robust Food safety, Quality control and Quality Assurance mechanism

2. Bring out Assam State Food and Nutrition Security Rules (under NFSA 2013): In order to ensure better access to safe and nutritious food to the eligible families under ICDS, MDM and Targeted Public Distribution System. The government should bring out “Assam State Food and Nutrition Security Rules” to ensure entitlements, transparency and public accountability in public funded food and nutrition programmes.

3. Follow the life cycle approach with a focus on first and last 1000 days and mainstream Nutrition in all development programmes. Inclusion of the last 1000 days means emphasis on expectant mothers and all that needs to be done to achieve optimum health parameters prior to conception and during pregnancy.

4. Review current anaemia strategy on an emergent basis, tackle all pervasive Anaemia first- The State needs an Anaemia policy based on cutting edge research: The Government of Assam after a systematic micronutrient survey needs to

KEY POLICY ACTIONS

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strategize a way to tackle anaemia including sickle-cell anaemia by using cutting edge research.

The status of anaemia and causes of anaemia are shared below.

I: Potential causes of Anaemia and key result area

5. Special screening programme of Tuberculosis affected people in vulnerable pockets to understand the prevalence and address the cases on priority basis.

6. Introduce Nutrition Budgeting: In the existing budget mechanism, it is very difficult to track the progress of various aspects of nutrition sensitive and nutrition specific interventions of the government. Thus, focusing on nutrition as the heart of the development programmes, the state budget may prepare a separate statement on nutrition. Assam may introduce Nutrition Sector Budgeting from the financial year 2018-19 to emerge as a Nutrition Pioneer in the country.

7. Emphasise Behaviour Change in regard to Food and Nutrition: Despite many programmes run by the government there is a high burden of under-nutrition; one of the reasons for this is nutrition behaviour change is not adequately emphasized in programming. This has to be complemented by advocacy, mass communication, capacity building on inter-personal communication and strategic use of data with a focus on home contact. The Behaviour Change Communication strategy, to start with, must target breastfeeding and appropriate complementary feeding.

II: Key result areas

Potential Causes Anaemia among age group

Current status of Assam-

NFHS-IV(15-16)%

Target and exemplar state-%

i) Infection and Inflammation ii) Iron Deficiency iii)Micronutrient deficiencies v)Genetic factors

Children 6-59 months 35.7 21.6- Nagaland

Non-pregnant women-15-49

46.1 23.7- Nagaland

Pregnant women-15-49 44.8 22.6- Kerala

All women-15-49 46 23.9- Nagaland

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8. State Hunger Mapping, Micronutrient prevalence and deficiency survey in partnership with reputed state and central institutions: Conduct a state Hunger Mapping and a comprehensive Nutrition and Micronutrient Survey that can provide prevalence and deficiency data down to Panchayat level. Similarly, conduct a survey/mapping of availability of key micronutrients in the soil, plants and species that can provide data at Panchayat level.

9. Bring out State Food and Nutrition Report with ranking of the districts and blocks in ascending order.

10.Improve access and accountability on key services and supplies: Most basic steps and emergent measures

III: Key Result Area

Key Behaviour related interventions- Status

Current status of Assam-NFHS-IV(15-16)%

Target and exemplar state-%

Children Breastfed within one hour 64.4 73.3- Goa

Children under age 6 months exclusively breastfed

63.5 77.2- Chhattisgarh

Children-6-8 months receiving solid or semi solid food along with breastfeeding

49.9 78.8- Manipur

Children 6-23 months receiving an adequate diet

8.7 31.1- Puducherry

Key services and supplies Current status of Assam-NFHS-IV(15-16)%

Target and exemplar state-%

HHs using improved sanitation facilities 47.7 99.4- Lakshadweep

Mothers who receive full ANC 18.1 66.4- Lakshadweep

Children 12-23-months fully immunized 47.1 91.3- Puducherry

Children aged 6-59 months received deworming medication

24.6 (ST-39.3)

(RSOC-13-14)

90+%

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11. Address Spousal Violence and Marriage Before 18 Years

IV: Key Result Area

12.Review and activate Nutrition Rehabilitation Centers (NRCs) for special programmes for severely affected malnourished children.

13.Bring out a Policy to control over Nutrition, Obesity and Non Communicable Disease(NCD)

V: Key Result Area: Obesity

14. Build capacity of the Self-Help Groups under Shakti mission programme to mainstream nutrition.

15.Bring out a comprehensive regulation and policy on food fortification with strong safety and safeguards measures and regulatory mechanism.

B. Medium Term-2-5 years

16. Setting the institutional arrangements right: • Establish a State Directorate on Food and Nutrition

Children aged 36- 71 months who received supplementary nutrition for 21 or more days in the month.

73.5(ST- 31)

(RSOC-13-14)

90+%

Particulars Current status of Assam -NFHS-

IV(15-16)%

Target and exemplar state-%

Spousal violence 24.5 2.6- Sikkim

Girls Married before age 18 32.6 0.9-Lakshadweep

Particulars Current status of Assam -NFHS-

IV(15-16)%

Target and exemplar state-%

Women who are overweight and obese 13.2 10.3- Jharkhand

Men who are overweight and obese 12.9 10.1-Meghalaya

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• Empowered State Food & Nutrition Commission • Establish a Bio-Fortification Mission and Bio-Safety Authority: Assam can be a

pioneer • A Centre for Excellence on Sickle-Cell Anaemia and Anaemia Management in

Assam to safeguard especially the women working in the tea garden areas. • Establish State Nutrition Resource Centre (like Chhattisgarh model of state health

resource Centre) • Build and strengthen ICDS sector level convergence mechanism backed by strong

MIS and empowerment of ICDS Sector Supervisors.

17. Emphasize Climate-Smart Agriculture: Climate-smart agriculture needs to be pursued to address nutrition needs along with an outreach strategy through participatory crop planning, partnering with bodies such as Farmer Producers Organizations as platforms with adequate focus on nutritional aspects at the family level like kitchen gardens, efficient water usage, mitigating risks keeping in mind drought, flood, cyclone etc.

18. Promote Dryland agriculture: Promote a policy breakthrough for dryland agriculture in Assam in areas without adequate rainfall.

19. Policy reforms to link NREGA to promote kitchen gardens, and bio fortified crops at panchayat lands/wasteland.

20. Introduce taxes on sugar rich soft drinks and stop proliferation of snacks full of trans-fats.

21. Bring out Assam State Safe Food Law: to address all pervasive food adulteration.

22. Introduce Special programme for tea garden and migrant workers: Specifically, anaemia reduction programme for tea garden workers, contract labourers and industrial workers and their children.

23. Build a cadre of women change leaders in Nutrition: Build a cadre of Change Leaders/ Volunteers of women and girls at hamlet level with reward and recognition mechanisms. These change leaders can address exclusion, increase home contact and lead the movement at the grassroots.

24. Priorities actions on Village Health Nutrition and Sanitation Day (VHNSD); in the hill districts such VHSNDs could be organized in collaboration with the Autonomous District Councils. Organise Special Gaon Sabhas on food and nutrition.

25. Anganwadi Centres to be declared as a Centre of Excellence and conversion of all Anganwadi centers into day-long crèches so that mothers of the 0-3 years’cohort, could be incentivised to send their infants to these centres. If that is done, the right to

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education of the siblings; the right to work of the toiling mothers, the right to food and nutrition security for the infants  and the right to appropriate shelter would be achieved.

26. Make Assam Open Defecation Free state by 2019. Conduct research/study using premier state and central institutes to assess the impact of Swachh Bharat Abhiyaan in preventing malnutrition, anaemia, micronutrient deficiencies and neonatal mortality.

27. IT enabled monitoring and participatory planning and setting nutrition surveillance system: Set up a nutrition surveillance system, with quick response in vulnerable hot spots. Introduce IT enabled monitoring to track the services and supplies.

28. Nutrition literacy and monitoring should be linked to participatory planning: Nutrition agenda must have the ownership of the Gaon Sabha and for this, there has to be a persistent effort to raise nutrition as an issue at the Gaon Sabha level. Also, the need for social audit provisions to monitor the government’s action plan through community monitoring for food security will transform the community empowerment process.

29. Institutionalise ration card portability system: Many vulnerable communities like migrating population are deprived of their food and nutrition entitlements due to non-portability of ration cards they possess when they are living outside the project area defined by the government of Assam/villages. Thus, ration card portability system may be institutionalized in the state.

30. Strengthen nutrition across value chain: The Food Corporation of India and state procurement agency must start silo storage and look at nutrition, prevent aflatoxin from farm to finger.

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The Coalition for Food and Nutrition Security, India is a group of policy and program leaders committed to fostering collaboration and evidence based advocacy for improved programs to achieve sustainable food and nutrition security. For queries, please contact Basanta Kumar Kar, Chief Executive Officer at- bkar@nutritioncoalition.org.in